1
Anticipating and Preventing ADEs:
Decreasing the Need to Rescue Hospitalized Patients from Opioid-related
Complications
Session BP5, February 11, 2019
Ashley Meyers, BSN, RN-BC, PCCN-K, Clinical Nurse Educator, Sparrow Hospital
Craig Havican, BSN, RN, Epic ClinDoc Senior Analyst, Sparrow Hospital
2
Craig Havican, BSN, RN
Has no real or apparent conflicts of interest to report.
Ashley Meyers, BSN, RN-BC, PCCN-K has the following
relationships to disclose:
Consulting Fees (e.g., advisory boards):serving as subject matter expert for
“Alternatives to Opioids in the ED” through Michigan Health and Hospital
Association (HIIN grant funded)
Fees for Non-CME Services Received Directly from a Commercial Interest or
their Agents (e.g., speakers’ bureau):previously served as an unbranded
onsite nurse expert for Mallinckrodt Pharmaceuticals, have not served in this
role in > 12 months
Conflict of Interest
3
• Background
• Identification of the problem
• Evidence-based solutions
• Implementation
• Results
Agenda
4
• Identify the key elements required to develop a robust MOSS
(Michigan Opioid Safety Score) which includes health risk
assessment, respiratory rate, and other clinical assessments
• Outline how to design an IT-enabled nursing workflow using
standard processes for nursing documentation to capture the data
elements required to generate a MOSS score and populate
clinical decision support and ordering
• Analyze how to incorporate unit level reporting tools to drive
MOSS assessment compliance by the nursing staff
• Outline how to generate a risk for respiratory depression care plan
for patients with high MOSS scores to help prevent the need for
rescue and promote timely intervention when rescue is necessary
Learning Objectives
5
Sparrow Health System
5
» Sparrow Hospital
» 10,500 Caregivers
» 733 beds
» 31,645 discharges
» CARF Accredited
» Level 1 Regional Trauma
Center
» Sparrow Carson (61 beds)
» Sparrow Specialty Hospital (30
beds)
» Sparrow Clinton (25 beds)
» Sparrow Ionia (22 beds)
6
Local Problem
• We are in an opioid public health emergency
• Opioid administration in hospitalized patients too often harms
those it is intended to help (ADE)
• Inpatient administration of the opioid antagonist naloxone for
overmedication is evidence of overuse or misuse
• Our data suggested that we could do better
• Timely identification and intervention for patients at risk or with
early evidence of respiratory depression should help
(effectiveness, safety, cost)
6
7
Local Problem
• Validated tools exist to decrease the risk of iatrogenic overdose
– Assessment of level of sedation
– Determination of Michigan Opioid Safety Score (MOSS)
– Triggering interventions before naloxone rescue is required
• Well- designed, pervasively used EMR tools should help improve
clinical outcomes and decrease costs
• No EMR-integrated tools and workflows to improve
7
8
Drivers to Take Action: 2012-2014
• Escalating national opioid crisis; Michigan’s ranking (10
th
, 18
th
)
• Joint Commission Sentinel Alerts
• American Society for Pain Management Nursing Guidelines
• MHA Keystone Center Opioid ADE Prevention Initiative
8
The Joint Commission, 2012
Jarzyna et al., 2011
9
Front-Line Nurses Leading the Way
• Sparrow Pain Resource Nurses (SPRNs) began looking at quality
data in 2014
• Nearly 1% of patients we were treating with opioids in the hospital
experienced opioid-induced respiratory depression (OIRD)
requiring naloxone rescue
• To improve this, we set a hospital goal to decrease the rate of
OIRD requiring naloxone rescue using:
– People: Governance, leadership, clinicians, IT
– Processes: Policies, workflows, Lean methods, PDCA
– Technology: IT (EMR); devices (ETC0
2
- capnography)
9
10
10
11
• Sparrow rate of opioid-
induced respiratory
depression (OIRD) as
measured by percent of
inpatients on opioids
requiring naloxone rescue
administration
• 2014: 0.72%
• 2015: 0.73%
• and increasing
Sparrow Baseline Data
11
Narcotics Accounting for
Naloxone Use
Fentanyl Hydrocodone/APAP
Hydromorphone Morphine
Oxycodone
12
2015 Naloxone Rate Trend Before
MOSS Implementation
12
• MOSS Documentation = 0%
13
Project Description and Goal
In acutely ill adult inpatients, does
implementation of a an EMR-integrated risk
assessment tool using accepted nursing
workflows that is aimed at preventing OIRD,
decrease the incidence of OIRD compared to
no risk assessment as measured by naloxone
use?
Goal: To decrease rate of IP naloxone rescue
to ≤0.65%
13
14
Benchmarks
• Naloxone Target Rate: 0.65%
• Numerator: # of patients received opioid &
naloxone
• Denominator: # of patient received opioid (any
route)
• Aligned with MHA Keystone Pain Management
Collaborative and HIIN
Khelemsky et al., 2015, Caymich, 2017
14
15
Design and Implementation
• The knowledge tools we decided to use
– Pasero Opioid-Induced Sedation Scale (POSS)
– Michigan Opioid Safety Score (MOSS)
• The IT tool we decided to use: Epic, because…
– Our key to the Sparrow Way and care transformation
– Where clinical care gets done…and documented
– Decision support: Risk scores, BPAs, care plans
• If this works, we can share it with Epic organizations!
15
Soto R, Yaldou B. J Perianesth Nurs. 2015;30:196
16
Design and Implementation
• Review literature
• Identify best practices
• People, process,
technology
• Gather a guiding coalition
• Communicate for buy-in
Decide what
good looks
like
• Assessment
documentation
• Scales & scores
• Nursing care plans
• CDS tools, displays
• Policy-supported
workflows
Build the
solution in
EMR
• Application testing
• Integrated testing
• MOSS education
• FMEA, address findings
• Policy implications
Test, Talk,
Teach
• Nursing leadership sign-
offs
• EMR workflow training
• Put into nursing practice
• Measure, monitor, adjust
Go-live &
PDCA
16
17
More about MOSS
• Combines
– Health risk assessment
– Respiratory rate
– Modified POSS (mPOSS)
17
Soto R, Yaldou B. J Perianesth Nurs. 2015;30:196
18
A SWOT Analysis to Inform Our
Conversion from Paper to EMR
18
Strengths
•
Supporting Literature
•
Pain Champions
•
Clear Assessment
Times Multimodal
Pain Management
Order Sets
Weaknesses
•
Double Documentation
(Paper & Electronic)
•
Turnover of RN/Nurse
Leadership
Opportunities
•
Improve Patient
Safety
•
Increase RN
autonomy
•
Decrease RRT
•
Decrease Narcan
Threats
•
Competing pilots
•
Equipment
•
Engagement
Sisco, Cooper, & Rayburn, 2014
19
19
© 2019 Epic Systems Corporation. Used with
permission.
20
Preoccupation with Failure to
Promote Success Every Step of the
Way: FMEA
Method
Audience
Other
Disciplines
Content
Key
Stakeholde
rs
Align with
other
initiatives
Timeline
Plan EMR
Build
Evaluate
Documentatio
n Committee
Across
applications
View for other
disciplines
Go-Live
Support
Timeline
Just in time
education
Educate
Implement
Ongoing PI
Risk Mgmt
reporting
PDCA follow-
up plan
Harpel & Giannini, 2014
20
21
How Health IT Was Used
• Use standard processes for nursing
documentation (EMR flowsheets) to
capture data for MOSS value
– Health risks: e.g., OSA, other
sedatives, age
– Respiratory rate: document
once, use many times
– mPOSS sedation assessment
21
22
How Health IT Was Used
• Program EMR to use
nursing documentation to
calculate MOSS value
• Display the MOSS value
where nurses can see and
interpret it
• Provide usable, actionable
CDS to drive best
practices
22
23
MOSS Scoring and Action
23
24
How Health IT Was Used
Nursing Documentation
Display of MOSS Value
24
© 2019 Epic Systems Corporation. Used with
permission.
25
How Health IT Was Used
Clinical decision support
• Alerts & advises to add
care plan or exclusion
• Adds and opens care plan
Unit level reports
• Department managers
• RRT nurses
25
© 2019 Epic Systems Corporation. Used with
permission.
26
How Health IT Was Used: Care Plans
26
© 2019 Epic Systems Corporation. Used with
permission.
27
Value Derived: Improved Processes
Adherence to Best Practice
27
Training
2
Training
1
Policy
Req Doc
28
Value Derived: Patient Outcomes
Surpassed ADE Benchmark
28
Mean
Naloxone
Rate
Relative
Change in
Naloxone
Rate
# of
Patients
Receiving
Naloxone
Per Year
Mean
Incidence
Per Month
2014 0.72% NA 179 14.9
2015 0.74% 2.6% 174 14.5
2016 0.70% -3.2% 157 13
2017 0.55% -23.6% 113 9.4
2018 0.52% -20% 103 8.6
29
Value Derived: Patient Outcomes
Jan-15
Apr-15
Jul-15
Oct-15
Jan-16
Apr-16
Jul-16
Oct-16
Jan-17
Apr-17
Jul-17
Oct-17
Jan-18
Apr-18
Jul-18
Oct-18
Naloxone Rate
Naloxone Rate (%) Trend Before vs. After
Implementing
EMR-Integrated MOSS Tool
Naloxone Rate (%)
Benchmark
Linear (Naloxone Rate
(%))
30
Value Derived: Improved Processes &
Outcomes
MOSS Documentation Naloxone Rate
31
Value Derived: Cost Avoidance as a Result of
Clinical Improvements
Mean
Naloxone Rate
Raw
Incidence
Per Year
Mean
Incidence
Per Month
Estimated Cost
Avoidance
(Raw Incidence vs.
Baseline Year)
2014 0.72 179 14.9
2015 0.74 174 14.5 $70K - $98K
2016 0.70 157 13 $308K - $431K
2017 0.55 113 9.4 $924K - $1,293K
2018 0.52 103 8.6 $1,064K –
1,489K
Overall $2,366K – 3,311K
Estimated cost per ADE: Non-ICU = $13,994; ICU = $19,685
Sultana J, Cutroneo P, Trifirò G. J Pharmacol Pharmacother. 2013; 4:S73-7.
32
Fewer Patients Harmed:
170
Cost Avoidance:
$2.3M - $3.3M
Totals: 2015 – 2018 YTD
33
External Recognition for our IT-enabled
Best Practice: Epic Clinical Program
© 2019 Epic Systems Corporation. Used with
permission.
34
External Recognition for our IT-enabled
Best Practice: ECRI Institute
• MOSS program recognition
• Better processes
• Naloxone reductions
• Greater staff comfort
• Criteria-based prescribing
restrictions (fentanyl)
• Safer order sets (PCA)
• Pushing nonpharmacologic
pain management modalities
(e.g., heat and cold,
aromatherapy, pet therapy)
35
• Capital expenses = $ 0
• Operational expenses = $57,375
Capital and Operational Expenses
Activity
Cost
PI/Project Planning; 120 total hours
Committee work; 20 total hours
Live and online Nursing Education; 1.5 hours each
Go
-Live Support; 40 total hours
EMR analyst time; 60 total hours
TOTAL
36
• Involve your frontline staff at the beginning
– Sense of ownership of the problem and solution
• Partner with IT team at the beginning of implementation planning
• One time education & training isn’t enough
• Technology and training does not ensure sustainability
– Clear expectations and accountability
Lessons Learned
37
Ashley Meyers, BSN, RN-BC, PCCN-K Ashley.Meyers@sparrow.org
Craig Havican, BSN, RN Craig.Havican@sparrow.org
Questions
38
References
Harpel, J., & Giannini, R. C., (2014). FMEA introduction [PowerPoint Slides]. Retrieved from
http://community.mha.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=12b34156-f4e1-46bd-
9b1d-e6a7019a76f4
Pasero, C., & McCaffery, M. (2010). Pain assessment and pharmacologic management. Elsevier Health Sciences.
Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J. S., Nisbet, A., Oakes, L. & Polomano, R. C. (2011). American
Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression.
Pain Management Nursing, 12(3), 118-145.
Soto, R., & Yaldou, B. (2015). The Michigan Opioid Safety Score (MOSS): A patient safety and nurse empowerment
tool. Journal of PeriAnesthesia Nursing.
Sultana, J., Cutroneo, P., & Trifirò, G. (2013). Clinical and economic burden of adverse drug reactions. Journal of
pharmacology & pharmacotherapeutics, 4(Suppl1), S73.
Sisco, L., Cooper, M., & Rayburn, V. (2014). Strengths, weaknesses, opportunities, threats analysis. Personal
Communication.
The Joint Commission. (2012, August). Sentinel event alert: Safe use of opioids in hospitals. Retrieved from
http://www.jointcommission.org
Yaldou, B., Cooper, M., & Soto, R. (2017). Inter-Rater Reliability and Reception of the Michigan Opioid Safety Score.
Journal of PeriAnesthesia Nursing.